To DRE or not to DRE, that is the question

Why won’t men go to the doctor? ‘We’re worried they’re going to poke a finger up our bum hole.’ (Caitlin Moran, What about Men?)

The digital rectal examination (DRE) has been a standard part of clinical examination for, well, for ever. It’s one of those procedures that has become embedded in both medical culture (‘If you don’t put your finger in, you’ll put your foot in it’) and popular cultural humour - any of you that are Billy Connolly fans like me will have seen the side-splitingly funny sketches he has done recounting his experiences of having DREs. 

And whilst there remains good reason for doing DREs in a number of situations, the rationale for doing one in the context of assessment for prostate cancer has been increasingly questioned over the recent past. I suspect many of us have done many DREs over the years for this, and have often been left wondering - ‘was that helpful in any way?’. Yet we have only been doing as requested - the NICE suspected cancer guideline NG12 states that for men presenting with LUTS, erectile dysfunction or haematuria we should ‘Consider a prostate‑specific antigen (PSA) test and digital rectal examination to assess for prostate cancer’ - that is a lot of men and a lot of DREs. And if a man has a raised PSA and we are referring, many cancer pathways still have a box to confirm that a DRE has been performed, yet the DRE will not change our management - we’re going to refer anyway.

These issues were discussed in an excellent BJGP review last year (BJGP 2024; 74 (740)) which questioned the routine use of DRE for assessment of prostate cancer. DRE can only allow us to feel the back wall of the prostate, and the majority of cancers are located in front so will never be detectable on DRE. 

But what’s the harm? We know there are false negatives with PSA, so surely it’s better to do a DRE for that odd case with a low/normal PSA? And here’s the rub, there is increasing evidence that routine DREs are causing harm - popular culture jokes about rectal examination have built a stigma around men seeing their GP about prostate concerns. The quote at the top from Caitlin Moran’s excellent book, What about Men?, when she asked a few men why they may be reluctant to see their GP, has now been borne out through survey data from Prostate Cancer UK - >2000 men were questioned about barriers to seeing their GP if they were worried about prostate cancer, and 60% said they were concerned about a rectal exam, and of that group >1/3 said they would not speak to their GP at all due to those fears. More concerningly, that fear was even more prevalent amongst black men, whom we know have twice the risk of prostate cancer compared to white men - exactly the group we do want to see at an earlier stage. 

But it does look like a DRE for prostate cancer assessment is going to become a thing of the past. A statement last month from the British Association of Urological Surgeons in association with prostate cancer UK has called ‘for an end to the routine use of the digital rectal examination (DRE), stating that it is no longer a useful test for prostate cancer’, and highlighting that ‘men do not need a 'finger up the bum’ to test for prostate cancer’.

So what is clear now is that if a man has a raised age adjusted PSA, we do not need to do a DRE and should just refer on an urgent suspected cancer pathway. If the PSA is normal a judgement is needed as to whether a DRE is then needed; the BJGP article gives helpful advice, asking us the age old question ‘will this change your management?’ They suggest a DRE should be considered in the context of a normal PSA if we still have clinical suspicion about prostate cancer e.g. higher risk men with a strong family history or black men, or concerns about advanced disease e.g. suspicious back pain. The BAUS statement sums up the state of play ‘A clinician using their finger to feel the prostate is a legacy of the historic pathway; it does not add clinical value but can be a major deterrent to men coming forward for checks’.